Application for Membership to the Caribbean Association for Rheumatology

Name and Degrees

First Name ______Middle Initial: ______

Last Name______

Degrees (list all degrees, reverse chronological order)______

Address

Professional Address

Institution ______

Department______

Address______

City______

State/Province______Zip/Postal Code______

Country______

Mailing Address (Check here if your professional address is your preferred mailing address)

Address______

City______

State/Province______Zip/Postal Code______

Country______

Phone/Fax/Email

Business ______

Home______

Email address______

Demographics

Gender______

Date of Birth ______

Caribbean Territory______

Rheumatology Training

Training Dates______

Institution and Training Director______

Year Certified in Rheumatology______

Year Certified in other specialties______

Membership Categories

Member

This section is for those who wish to be considered for membershipresiding in the Caribbean (Ordinary members) or non-residents (Affiliate members).

I am applying for: (Please choose one) Ordinary or Affiliate Membership with CAR

Enclosed is a letter of sponsorship from the following CAR member:

(1)______

Associate Member

This section is for those who wish to be considered for membership as a rheumatology or medicine trainee. This means that you are currently enrolled in an accredited rheumatology or medicine program.

I am applying for membership as a (please select one) Rheumatology or Medicine Trainee.

I have enclosed a letter from my training director verifying that I am currently enrolled in a rheumatology or medical training program.

My Training director is ______

Projected Date of Program Completion: ______

I am applying for membership as a Student and have enclosed one letter of sponsorship from my program director or advisor confirming my enrollment.

Training Director: ______

Fellow

A fellow is a member of CAR, who has rendered significant service to the organization. This designation can only be achieved by election by other members of CAR.

Submit Application

I have read and understand the by-laws ( published on the CAR website) and agree to abide by the Code of Ethics of the Caribbean Association for Rheumatology, and I verify the information contained within this application is accurate.

By checking this box, I agree to and confirm the Application Terms & Conditions as set out in

the CAR’s By-laws.

Applicant’s Signature: ______

Date: ______

Amount that will be paid via PayPal on the website: $______

Please indicate the category of membership for which you are applying.

  1. Fellows:

A person who is distinguished by his/her work in Medicine or Research, in the Caribbean or abroad and has contributed to the advancement of Rheumatology or who has rendered conspicuous service to CAR. Fellows shall be elected by CAR from among persons who at the time of their election are Members of CAR and such election shall be announced at the Annual General Meeting.

  1. Ordinary members: $100 one time entrance fee, $100 annual subscription.

A person who is a registered medical practitioner working in the field of Rheumatology and a basic scientist whose research interests are in rheumatic diseases. To apply as a Member, complete the application and supply a letter of sponsorship from a current voting member of the ACR.

  1. Affiliated Members: $100 one time entrance fee, $100 annual subscription

These shall be non-residents of the Caribbean region who contribute to the work of the Company by research, correspondence or otherwise and whose application for affiliation shall be subject to approval of the Directors on such conditions as shall be determined by the Directors. To apply as a Member, complete the application and supply a letter of sponsorship from a current voting member of the ACR.

  1. Associate Members: No entrance fee or annual subscription fee

Theseshall be individuals pursuing regular training in medicine or medical research which will eventually lead to membership CAR. To apply, complete the application and supply one letter of sponsorship from your program director or advisor confirming your training, preferably with start and end dates for your